HomeMy Public PortalAbout10816 DAINES DR_Electrical__ Wm that I have a certificate
DECLARATION CE-663 I0/81 APPLICATION FOR ELECTRICAL PERMIT {�
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I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY -
copy thereof(Sec.3800.Lab. C.)
Policy No. - Company FOR APPLICANT TO,FILL IN JOB O�6 E /
❑ -
Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS /�
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Certified copy is filed with the county building inspection
1 & 2-Family.Sq.Ft. $ — $ LOCALITY Gr N- , G�
department. Multi-family Sq. Ft. NEAREST,
OR
CROSS ST
Date Applicant
Residential Swimming Pools _ _ _ OWNER O /1 io
C� /ij ��J `f ✓IV
L„•'V�✓ �J
FIRM NAME
-CERTIFICATE OF EXEMPTION FROM WORKERSOutlets:Res .Light Sw. I MAIL /3a
COMPENSATION INSURANCE. ADDRESS U
(This section need not be completed if the work involved by the First 20 CITYTel.No. Q
permit is for one.hundred dollars ($100).or less.) Total No. Additional n� J/ �lQ
I certify that in the performance of the work for which this permit PLAN CHECK .
.APPLICANT
is issued, I shall not employ any person in any manners as to ,
become subject to the Workers'Comp s on Laws. Lighting Fixtures First 20 - ADDRESS
'q);'Yp ��)),,�� �, /I Additional
Date q-ac- / V Applipant. r/eVN1A_ $,�'� Total No. - CITY Tel.No.
NOTICE TO APPLICANT: if, after, making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W M._ ADDRESS
provisions or this permit shall he deemed revoked. Top FAU W.H. CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that.l am licensed under.provisions of Chapter 9 LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Dista. — Room Air Coad. Class. -
REG.NUMBER
Professions Code, and my license is in full force and,offact.' DISTRICT NO. PROCESSED BY
.Power Apparatus 8 Large Appliances
Size& Type HP,KW,KVA, or KVAR 0
License Number Lic.Class - Up to 1 Inc[. FINAL U
Contractor" - Date Over 1 to 10 Incl.
DATE
VALIDATION 0
❑
Over 10 to 50 Incl. 'U: FINAL "
1 am exempt under Seo. Over 50 to 100 Inc.
BY -f" f+. _ W
88P.C.for this reason Over 100 D �. N
Services,Swbd.,MCC& Panelboards t Zf`22 Z
Dater 0 - 200 Amp.Under 600 V } r! "I (
Signature 201 - 1000 Amp. Under 600 V - •�•� -
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint.Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances
-
HOME OWNER-BUILDER DECLARATIONi
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit - y
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits C A
Code): - . ...
AL.GT.T
-
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 6 A07 1.00
is not intended or offered for sale (Section 7044, Business . Other(See Complete Fee'Schedule) ® 1 TTEMS .
and Professions Code). TOTAL 3 1 -00
•CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction Is agency for the ' - CHECK 31.Ob
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) '
Civ.c.).
PLAN CHECKING FEE (:RANGE
Lender's Name PERMIT ISSUING FEE - .�3 QDOD-11001 .7/2
Lender's Address 0/90
_
certify that have read this application and state that the above TOTAL FEE �� e-
2956 1 AM v9.`j_
information is correct. I agree to comply with all County ordinances 1fl .
and State laws regulating Electrical wiring, and hereby authorize 1 � �
resentatives of thisCo nt to enter upon the above-mentioned
ro erty for raps
ion Pur o s. ; _
/j Q SEE REVERSE FOR EXPLANATORY LANGUAGE j I �.j_I
' �— �I J7 ' -1101 9Ii0/90
Signature of Permittee Date ,557 1 AMv7y9 e'
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